Vaginal Birth after Caesarean Section (VBAC)
Author(s) / Dr Neelima Dixit
Dr Matthew Toal
Dr Amit Shah
Dr Anil Gudi
Dr Maryam Parisaei
Version / 1.1
Version Date / November 2010
Implementation/approval Date / November 2010
Review Date / November 2012
Review Body / Department of Obstetrics and Gynaecology and Department of Midwifery, HomertonUniversityHospital
Policy Reference Number

Summary- There is widespread concern about the increasing number of births by caesarean section (CS). Judicious promotion of vaginal birth after CS is a reasonable strategy to counter the rising CS rates. This guideline presents the best available evidence to facilitate antenatal counselling in women with prior caesarean birth and to inform the intrapartum management of women undergoing planned VBAC.

Introduction- The estimated success rate of VBAC ranges from 72-76 % ( RCOG 2007) Pregnant women with a previous section may be offered either a planned VBAC or elective repeat caesarean section (ERCS) .The risks and benefits should be discussed in the context of the women’s individual circumstances including her personal motivation and preferences to achieve vaginal birth or ERCS. VBAC failure, resulting in emergency caesarean section and rarely in uterine rupture, can be minimised with appropriate patient selection, good antenatal counselling, careful review of case notes and adherence to written guidelines. Senior, technical and logistical backup on the labour ward will also minimise the risk.

Scope-This policy applies to all employees of the Trust in primary, community and secondary healthcare who are involved in the care of women during pregnancy, birth and in the postnatal period. It may also apply to public health, trust managers, pregnant women, their families, birth supporters and other carers.

Antenatal management

  • A planned vaginal birth after a previous CS should be recommended for women whose first CS was by lower segment transverse incision, and who have no other indication for Caesarean Section in the present pregnancy (Appendix 1).
  • Women with one or more previous CS requesting VBAC are recommended to discuss this with a consultant in the antenatal period.
  • The woman’s previous notes should be requested by the booking midwife where possible and made available for her clinic appointment. There can then be be a review of notes of previous CS to identify any operative complications or perioperative infection.
  • The reason for the previous CS if known should be clearly documented in the hand held notes.
  • Women with two previous uncomplicated low transverse caesarean sections, in an otherwise uncomplicated pregnancy at term, with no contraindication for vaginal birth, who have been fully informed by the consultant obstetrician, may be considered suitable for planned VBAC.
  • All women who have had one previous Caesarean Section (CS) should be referred to the RCOG information leaflet for VBAC.
  • Women can be referred to the RCOG VBAC leaflet:
  • An antenatal appointment to discuss mode of delivery should be made at 20 weekswith a consultant obstetricianand again to confirm if needed by 36 weeks. The Trust’s CS discussion tool should be used to record the discussion and a summary of this discussion should be recorded in the notes which must also include a plan for monitoring of the fetal heart rate.(Appendix 2).
  • It is recommended women requesting an elective repeat CS should have a clear plan in their notes for their care if they spontaneously go into labour prior to this date. This should include delivery by 39 weeks gestation.
  • Women requesting planned VBAC delivery should be advised to deliver on Consultant Led Delivery Suite.
  • Women planning VBAC do not meet criteria for midwifery led care. If a woman requests delivery outside of the consultant led unit, they must be offered an appointment with a consultant obstetrician and the consultant midwife, preferably a joint discussion.

Care of women post 40 weeks gestation choosing VBAC

  • All women who are keen for a VBAC but who have not delivered by 39-40 weeks should be offered a consultant appointment at 40 weeks.
  • Decision with respect to Induction of labour for women with previous CS should only be made by a consultant as current evidence remains controversial. Increased risk of uterine rupture with induction of labour must be clearly documented.
  • Clear plans should be documented by the registrar or consultant regarding her management if she does not go into spontaneous labour at 40+12/40.

Women admitted at term for planned VBAC with PROM or ‘contractions’ who are not in established labour

  • Clear plans should be documented by the registrar regarding her management if she does not go into spontaneous labour.
  • There is no clear guidance about optimum management for this group of women.
  • Each case must be assessed by the obstetric registrar and a clear management plan must be recorded in the notes after liaising with the consultant obstetrician if necessary.
  • Those women who are suitable for expectant management must be reviewed at least 12 hourly by the obstetric team.
  • Women undelivered 24 hours after admission must be discussed with the obstetric consultant and the management plan reviewed and documented.

Intrapartum Management

  • Women having a VBAC should be under consultant care.
  • Maternal BP and pulse should be recorded hourly as a fall in blood pressure or raised pulse may indicate uterine rupture.
  • IV access should be sited and blood sent for full blood count and a group and save.
  • Continuous fetal heart rate monitoring with CTG or STAN should be used.
  • Immediate referral to the obstetric team is required in the presence of a suspicious or pathological fetal heart trace as this maybe an early sign of uterine rupture (Appendix 3)
  • Four hourly assessments in established labours should be performed unless otherwise indicated
  • Slow progress of less than 0.5cms per hour in the first stage or slow progress in the second stage should warrant immediate referral to the Obstetric team.
  • Women should be advised not to eat.
  • Oral ranitidine and metoclopramide (10mg T.D.S) should be given regularly until delivery.
  • Augmentation of labour should never be considered without discussion with the consultant first and increased risk of uterine rupture explained to women.
  • Epidural analgesia is not contra-indicated but should not be routinely recommended unless the patient’s BMI is more than 40.
  • If the reason for the previous Caesarean Section was failure to progress in the second stage or was for failed instrumental delivery, progress in the second stage (position and descent of the presenting part) should be carefully monitored by both abdominal palpation and vaginal examinations. If there is no descent and rotation after an hourthe management plan should be reviewed by a registrar or a consultant.

Postnatal Management

  • Manual exploration of the uterus in women who have had a previous CS is not recommended.
  • An opportunity for debriefing should be offered irrespective of mode of delivery.
  • Routine postnatal care should be given to these women and their babies (see caesarean section guideline).

Audit and monitoring

Measurable Policy Objective / Monitoring/ Audit / Frequency of monitoring / Responsibility for performing the monitoring / Monitoring reported to which groups/committee, inc responsibility for reviewing action plans
Responsibilities of relevant staff groups / Audit / Yearly / Nominated Maternity lead / Departmental audit meetings, maternity risk management review and Friday morning meetings
Documented antenatal discussion on the mode of delivery / Audit / Yearly / Nominated Maternity lead / Departmental audit meetings, maternity risk management review and Friday morning meetings
Documented plan for the place of labour / Audit / Yearly / Nominated Maternity lead / Departmental audit meetings, maternity risk management review and Friday morning meetings
Documented individual management plan for labour / Audit / Yearly / Nominated Maternity lead / Departmental audit meetings, maternity risk management review and Friday morning meetings
Documented plan for labour should this commence early / Audit / Yearly / Nominated Maternity lead / Departmental audit meetings, maternity risk management review and Friday morning meetings
Measurable Policy Objective / Monitoring/ Audit / Frequency of monitoring / Responsibility for performing the monitoring l / Monitoring reported to which groups/committee, inc responsibility for reviewing action plans
Documented plan for labour should this not commence as planned, that has been discussed with the consultant obstetrician / Audit / Yearly / Nominated Maternity lead / Departmental audit meetings, maternity risk management review and Friday morning meetings
Documented plan for the monitoring of the fetal heart in labour / Audit / Yearly / Nominated Maternity lead / Departmental audit meetings, maternity risk management review and Friday morning meetings

Appendix 1

Contraindications to VBAC

  • One previous classical caesarean section.
  • Women with previous uterine incision other than uncomplicated low transverse should be assessed by a consultant with full access to details of previous surgery.
  • Previous uterine rupture (risk of rupture unknown).
  • Three or more previous caesarean deliveries (reliable estimate of rupture unknown).

Appendix 2

Trust vaginal birth after caesarean discussion tool

Advantages of successful VBAC:

  • Greater chance of an uncomplicated normal birth in future.
  • Shorter recovery period and shorter stay in hospital.
  • Less abdominal pain after birth.
  • Not having surgery.

When is VBAC likely to be successful?

  • Previous vaginal birth is the single best predictor for successful VBAC.

Risk factors for unsuccessful VBAC:

  • Induced labour, no previous vaginal birth, BMI >30 and previous LSCS for dystocia.
  • Other risk factors associated with decreased likelihood of VBAC success should be shared during the antenatal counselling where relevant.
  • VBAC at or after 41 weeks, birth weight >4000g, no epidural anaesthesia, previous preterm CS, cervical dilatation at admission <4 cm, less than 2 years from previous CS, booking maternal age >39, non white ethnicity and short stature.

Disadvantages of VBAC:

  • Scar rupture: This occurs in two to eight women in 1000 (0.5%). There is a chance that uterus will weaken and rupture. If the scar opens completely, this may have serious consequences for the woman and her baby.
  • Emergency caesarean section: This happens in 25 out of 100 women (25%). This is only slightly higher than if the woman was labouring for the first time, when the chance of CS is 20 in 100 (20%).
  • Blood transfusion and endometritis: women choosing VBAC have 1 in 100 (1%) chance of a blood transfusion or endometritis compared with elective repeat caesarean section.
  • Risks to baby: The risk of baby dying or being brain damaged (birth related prenatal death or hypoxic ischaemic encephalopathy) is two in 1000 women or 0.2%.This is higher than elective repeat caesarean delivery one in 1000 or 0.1%.

Advantages of repeat elective delivery (ERCS)

  • Virtually no risk of uterine scar rupture, avoids risks of labour and particularly the risk of possible brain damage or still birth from lack of oxygen during labour (one in 1000 or 0.1%), knowledge of date of delivery.

Women considering the options for birth after a previous caesarean should be informed that elective CS may increase the risk of serious complications in future pregnanciesincluding the following (RCOG 2007):

  • Placenta accreta
  • Injury to bladder, bowel or ureter
  • Ileus
  • The need for postoperative ventilation
  • Intensive care unit admission
  • Hysterectomy
  • Blood transfusion requiring four or more units
  • Duration of operative time and hospital stay

Appendix 3

Signs of uterine rupture:

  • Abnormalities in FH
  • Bleeding vaginally
  • Pain between contractions
  • Abdominal tenderness
  • Haematuria
  • Sudden cessation of contractions
  • Pain breaking through a previously effective epidural

References

Royal College of Obstetricians and gynaecologists (2007) Birth after previous caesaerean birth Green-top guideline No 45 RCOG

RoyalCollege of Obstetricians and gynaecologists (2008) Birth after Previous section – information for you. September 2008

The current management of vaginalbirthafter previous caesarean delivery
Obstet Gynaecol (Lond) 2007 9: 77-82.

National Collaborative Centre for Women's and Children's Health, 2004

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